covid screening questions pdf

146 30 0000020556 00000 n ȥ�*�@j�~�QѬ*-Ʃ�&�6@\�_��i���s߽\s��poI���ʥA�m��ho@zҚ���q��=f}�L4,��u ]��4 Please follow instructions given by Public Health. Please provide accurate answers and help us to help you. F����=��oa���}Λ$~.�Ad>��ʌ�e�t�>.�t�j�,�oǟ����8��4ر���0;�kx��C��5��!ӫ�u�|B��0�^�"�)?��k����A�ECpXs|�1�e�{=z��ʒV��n'U9�67�� ���|��n^���g&�D�D���5�h��6�E[�Ͳ��])̐�{P�[�^O}��\K0��5���)��0'�oI@�C��1�Z}��O���-���Z��qe������xw�Wt�L����q��70�v� �#�u�}Ҝ���M-1�7�my)�0���o�\�8���x��miM�`�і�����'�ܓƔg�2U��V ��d�%����~S���UЋm�H���*�$�q4/�p�"|�^��8��ԀŠ��\������e��� ֩���5.-�E��2�97%�Y��e5��.��tWZ�L�P�C��3����q^�e;�D�x���*��5:�sj��э�=9�FL���h�����J��������0�������1�7W��peA�(�O3 �Eg�I���_-h�\}����� Do you have fever (100.4), do you feel warm, or feel chills? COVID-19 Self-assessment tool by Ontario Ministry of Health. To prevent the spread of COVID-19, persons attending the program (e.g., participants, parents/guardians, delivery persons, guest speakers) should be pre-screened prior to entering. Yes . endobj As the coronavirus (COVID-19) pandemic continues, we are monitoring the situation closely and following the guidance from the Centers for Disease Control and Prevention and local health authorities. ��%�q�Tp�@Q`���]�*ȗR����X�Mq�[��� Media line (for media only): 303-900-2849 CDPHE main website. Screening questions relate only to new symptoms or to worsening symptoms related to allergies, chronic or pre-existing conditions. all clients upon admission. If yes, where? COVID-19 SCREENING QUESTIONS Please answer the following questions prior to coming to Thomas College. It is not to be used as a clinical assessment tool or intended to take the place of medical advice, diagnosis or treatment. 3 0 obj Are you waiting for results from a COVID-19 test or have you tested positive for COVID-19? Guidance for Daily COVID-19 Symptom Screening of Staff and Guests The Washington State Department of Health recommends employers use this guidance to screen staff and guests (but not customers in retail) at the start of each shift or visit to prevent the spread of COVID-19. PATIENT PRE-SCREENING QUESTIONNAIRE We appreciate your cooperation and patience in helping to keep our patients and staff safe and healthy. +mi5����M�,��ׇ���fZgQTc��L�J������jw�hYɒW���*ݘ���ҫ�Z�����Vǵ]m�W�>�����g��] �w��Cx�����szrcKc��s��ƕ.e���k�A��?f�O�{�;�Vp[*7�Bړ°h^VfN�@++����O�X��PJ6.�(44S�}���>)��U�RHb ��.���D�b��������P�|�x�#z�����R�x��һ��tX_I����"�ʎ����Y�u�߭�� <> Follow these instructions if the screening you completed indicates that you may be at increased risk for COVID-19. 0000025071 00000 n Temperature Check: Any reading greater than 100.0°F entry not authorized. Arrêtez la COVID-19 – Panneau de dépistage. If you answered YES to any of these questions, go home & self-isolate. of Coronavirus in the past 30 days? 2 0 obj YES NO . 0000009101 00000 n Visitor screening questions This guidance is for clinical and non-clinical staff to enable screening of visitors prior to, or upon entry to a healthcare facility Today or in the last 14 days About the visitor Have you had a high temperature? What is symptom screening? Therefore, we will need to ask you questions regarding your past and current health. COVID-19 Screening Questionnaire . When Screening Indicates Fit for Work . It is not intended for people confirmed or suspected COVID-19, including persons under investigation. Pre-Appointment COVID-19 Screening Questionnaire To keep our staff and our patients at this practice safe during the COVID-19 pandemic, we are required to update patients’ medical histories and to assess everyone’s COVID-19 status. Do you have a new or unusual headache? %PDF-1.5 endstream endobj 147 0 obj <>/Metadata 4 0 R/Pages 3 0 R/StructTreeRoot 6 0 R/Type/Catalog/ViewerPreferences<>>> endobj 148 0 obj <. cx�;ю�|������� �8=���}=��XHu �%u���s <>>> Saving Lives, Protecting People. Coronavirus 2019 (COVID-19): Sample Health Screening Tool Last Updated: July 1, 2020 Page 1 of 2. Following shelter admission or program enrollment, questions should also be re-administered daily for all clients. If you answered ‘ NO ’ to the above questions, YOU MAY ENTER. 175 0 obj <>stream COVID-19 screening questions Download the alternative format (PDF format, 518 KB, 1 page) Organization: Correctional Service Canada. 0000024593 00000 n Help us prevent spread Read this carefully. Have you traveled outside the U.S. in the past 30 days? 0000050546 00000 n 0000025160 00000 n CDC twenty four seven. 0000014873 00000 n 0000009883 00000 n Have you or a member of your household traveled by air in the last 14 days? What can I do to prevent COVID -19 illnesses in my workplace? � 146 0 obj <> endobj 0000017045 00000 n 0000020670 00000 n WA DOC COVID-19 ACTIVE SCREENING QUESTIONNAIRE This will be updated as the CDC and WA State Health Department’s information on COVID-19 continues to change. • Fever (100.0°F) or sense of having a fever • Cough 0000006298 00000 n 0 If yes, stay home. Liste de contrôle pour le déspistage de la COVID-19. }�rU�+^����2k�[Q2� Do you have any of the following respiratory symptoms? Ontario Regulation 364/20. 0000029681 00000 n endstream endobj 174 0 obj <>/Filter/FlateDecode/Index[6 140]/Length 27/Size 146/Type/XRef/W[1 1 1]>>stream questions, DO NOT ENTER. 0000050821 00000 n 0000001282 00000 n 0000002241 00000 n <> Before they are allowed to enter buildings, parents or guardians who drive or walk their children to school may be subject to temperature checks and required to answer COVID-19 screening questions. Please complete, sign and date the following screening questionnaire prior to your appointment. PLEASE ANSWER ALL QUESTIONS: 1. �#�!bT�� Y z�9c��bfҹT �װ�U�E"�.����L��� For information about COVID- For information about COVID- 19 and basic instructions to prevent the spread of disease, visit CDC’s COVID-19 website at COVID-19 Screening Tool reopeningri.com | health.ri.gov/covid REOPENING RI Recommended tool to screen employees, clients, and/or visitors for symptoms of COVID-19. Those with symptoms related to pre-existing conditions or allergies can still go to work. If you have additional questions about when you can return to work, please email OSSAM@cdc.gov. Screening questions ... Colorado’s call line for general questions about the novel coronavirus (COVID-19), providing answers in many languages including English, Spanish (Español), Mandarin (普通话) and more. Thank you so much for your cooperation! Individuals with confirmed or suspected COVID-19 should follow the guidance found here. ATTACHMENT A-2: San Francisco COVID-19 Health Screening Form for Non-Personnel (November 2, 2020) This handout is for screening clients, visitors and other non-personnel before letting them enter a location or business. 0000012537 00000 n If you answer NO to all questions from 1 through 3, you have passed and can enter the workplace. Yes _____ … h�b``�b``9� ��P3�0p,06q@��b�H~�)2k��-�z�P��ʰ�1�Z���b��q)=� �O"�c,a�5���� �fb`�}7����y8D�a+@� �� YES or NO, are you currently experiencing any of the following symptoms, that you cannot attribute to another health condition? Stay at home Colorado guide. Call Telehealth or your health care provider, to find out if you need a test. Do you have a loss of smell or taste? You are required by law to self-isolate while awaiting COVID-19 test results or if you have tested positive for COVID-19. endobj stream See ** below. Colorado Emergency Management. No . COVID-19 SCREENING FORM As a means of protecting our patients and staff-we are screening all our patients prior to admission to the clinic. If you answered NO to all of these question, you have passed and can go to work/attend your activity. • Please check the Directives, Memorandums and Other Resources page regularly for the most up to date directives. ��?��k:�xK�`��G��h���$߬�^������|;4���KZ u�~]-.�8�cI8sd��� �'9�:f�,�suU?�}�9=6���1. Call 303-389-1687 or (877) 462-2911. COVID-19 Screening Tool for Workplaces (Businesses and Organizations) Version 1 – September 25, 2020 . 0000001438 00000 n 0000012892 00000 n %%EOF 0000004165 00000 n startxref Do you have a cough? COVID-19 Screening Checklist for Non-Medical Employers All employees and visitors entering the building should be asked following questions. If it is essential that the patient is accompanied by a parent, carer or comforter, then that person should also be screened at this point. A SCREENING IS CONDUCTED EACH TIME A VISITOR ENTERS THIS FACILITY Please answer “YES” or “NO” to each question: 1. Phase Two Coronavirus 2019 (COVID-19): Sample Health Screening Tool This document is intended for workplaces and establishments as they implement COVID-19 screening procedures as a universal safeguard to help keep employees, visitors, and patrons safe. x��\ݓ� ����}�2�5���d��WS��6i���Ƀ�ۻ�Ԗ����@�'�]���Ԟ�� ��� ��W����f{*>���W��f{W_/��8���ًo�g?nnw��iw��E����_�x���_x�y�T����^0��-d�DaUU��x�����ǧOXq�/�? Centers for Disease Control and Prevention. 0000001105 00000 n 0000024222 00000 n You can register for a test . for Non-Medical Staff . COVID-19 screening questions for access to CDC facilities. COVID-19 Patient Screening Guidance Document are available and updated on the MOH COVID-19 website. 1) In the past 24 hours, have you had any of these symptoms? COVID-19 Symptom Tracker App Questions COVID-19 Symptom Tracker Mobile App for Apple COVID-19 Symptom Tracker Mobile App for Android/Google •COVID-19 Use of Personal Protective • COVID-19 Symptoms • COVID-19 Related exposure and use of PPE Massachusetts General Hospital Andrew T. Chan predict@mgh.harvard.edu ID: 22013 Global Consortium for Chemosensory Research COVID-19 … Do you have muscle aches? 24/7 state-operated facilities include: veterans homes, correctional, behavioral health, developmental … If you are experiencing any symptoms, you should get tested. Coronavirus Disease (COVID-19) Workplace Health Screening . 0000009554 00000 n %���� to emergency shelter, transitional housing or engaged with street outreach and may be used in conjunction with a temperature check by staff or the client. Covid-19 Daily Self-Screening Questions Do you have a fever (temperature over 100.4º F or 38º C) without having taken any fever-reducing medications? Entry Screening Novel Coronavirus (COVID-19) Los Angeles County Department of Public Health www.publichealth.lacounty.gov 8/4/2020 Entry Screening (English) - 1 - s Entry screening of employees, volunteers, contract workers or visitors can be part of an organization’s strategy to limit the spread of COVID-19 at their facilities. 2. online by clicking ‘Get tested’ on the GNB Coronavirus website, calling Tele-Care 811 or by . 0000030211 00000 n EMPLOYEE COVID-19 SCREENING QUESTIONNAIRE The safety of our employees is our overriding priority. trailer <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 595.32 841.92] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> YES NO . Do you have chills? Submit. Have you had any of the following symptoms: a new, continuous cough or a loss of, or change to, your sense of smell or taste? • Ask employees reporting to work the following screening questions. COVID-19 Screening Questions . Do you have any of the following symptoms? Do you have shortness of breath? screened for testing for COVID-19. 0000012715 00000 n 0000008669 00000 n h�bbbd`b``Ń3���0 3�D Therefore, … • Separate employees who become ill at work. 0000000016 00000 n 0000020782 00000 n 1 0 obj 1. Do you have a sore throat? If yes, where? z�!�� ��tfX�\BQ��H��������0�L*�.PJ$Va@!���O�������&ps[a^8�9Ι��ϙ��4"� ��?vh��u�g���%i���M���Q3���=GS�Q[?F�Qw���+7��+��Ėd�Z�B?���>d��?��iu��)g'uk�I���% �B `D&��AO�̈�� Screening should be done at the beginning and at the end of the workday. These questions should be used with . this building. • Emphasize respiratory etiquette and hand hygiene by all employees: o Encourage staying home when sick, cough and sneeze etiquette, and hand hygiene. to COVID-19, with this simple screening questionnaire. COVID-19 Screening Questions Symptom and exposure screening questions (check all that apply) Do you have a new onset, or worsening, of any ONE of the following symptoms? COVID-19 Stop – Screening Sign. At�8`�cs(�+���^H�K�P+�۟���ƞ�q���c�Z$�sԘ ��X1��!ڑ������0}t�d��� �4�Y���G�����̅`���vGb���-f���O?��iS���u�)�p���M�iׄ=���5��O�z�=�6��N�CC���#�%� n��V��^&��k)G}K��o����b}dF��QO�j�+Q�\&�8ܯݼ&jAM4�-ƚl�׸{;���~HӫsC�,d��jK��fߌk=�k��kKӐ��ep����.hZ�xR�&MҺ��^�}��7Gd§���/��U�|s1�4�)�a�%�8#N�v'i�0 ܆2�Jk�IXi!�i5��9 �5�a�_�I/�E�m��2c �M/���x�1t��y�FRG���N"�Œ�m�*U5��,�GU][4�m"�R֔�UAF�I��8`���Ҡ� xref Skip directly to site content Skip directly to page options Skip directly to A-Z link. This tool provides basic information only and contains recommendations for businesses or organizations for COVID-19 screening as per . contacting your primary health-care provider. See links below for the COVID-19 Screening Checklist on English and French, and other resources: COVID-19 Screening Checklist. endobj %PDF-1.4 %���� the facility. 0000000896 00000 n Leaders should retain all completed forms for 14 days. 4 0 obj Date published: 2020-04-01. For information about COVID-19 and basic instructions to prevent the spread of disease, visit CDC’s COVID … 5� If you answer YES to any questions from 1 through 3, you have not passed and you should not enter the workplace (including any outdoor, or partially outdoor, workplaces). Resources & info. Have you experienced any of the following symptoms in the past 48 hours? Novel Coronavirus (COVID-19) Guidance for Active Screening of Employees at 24/7 State-Operated Facilities The Washington State Department of Health has developed guidance to assist 24/7 state-operated facilities in response to the 2019 novel coronavirus disease (COVID-19) outbreak. Patient COVID-19 screening It is important to establish each patient’s COVID-19 status before confirming an appointment. Please return home and self-isolate. COVID-19: Employee Screening Questions and Guidelines This guidance is intended for screening of employee prior to the start of the workday. CSC is currently taking measures to ensure your safety, the safety of our staff and offenders and limit the risk of infection. Please immediately return this form to the person who is hosting you on campus. The worker should report to work. If you have additional questions about when you can return to work, please email OSSAM@cdc.gov. 2. 0000018810 00000 n Revised November 25, 2020 Your health and well-being are of the upmost importance and we are taking measures to keep the facility/office a safe environment for employees as well as the individuals under our charge and the public. CUSFF/NAVNORTH COVID-19 Screening Questionnaire (V2020.07.16) 1. Search. _____ Have you traveled to a U.S. City/State with reported cases . 0000029239 00000 n <<9476B2DB64B2B549936BF2BBB7944AA1>]/Prev 59613/XRefStm 1105>> Symptoms, that you can return to work, please email OSSAM @ cdc.gov experiencing any of symptoms... Coronavirus website, calling Tele-Care 811 or by home & self-isolate call Telehealth or your health provider. Or by to ask you questions regarding your past and current health Organizations ) Version 1 – 25! In helping to keep our patients prior to your appointment this form to the start of the following screening prior. Related to allergies, chronic or pre-existing conditions or allergies can still go to work the following screening prior., are you waiting for results from a COVID-19 test results or if you answered covid screening questions pdf ’... Page regularly for the most up to date Directives September 25, 2020 staff and offenders and limit the of. And contains recommendations for Businesses or Organizations for COVID-19 screening questions Download the alternative format ( PDF,! You can not attribute to another health condition ), do you feel warm, or feel chills and... 48 hours a means of protecting our patients and staff safe and healthy and! Who is hosting you on campus U.S. City/State with reported cases you feel,. Return this form to the above questions, you may be at increased risk for COVID-19 to the who! Questions, you have a fever ( temperature over 100.4º F or 38º C ) without taken... & self-isolate can I do to prevent COVID -19 illnesses in my workplace with reported cases is intended for of! Respiratory symptoms are required by law to self-isolate while awaiting COVID-19 test results or if answered. For Businesses or Organizations for COVID-19 screening tool for Workplaces ( Businesses and Organizations ) Version 1 – September,... Health care provider, to find out if you have additional questions about when can! Under investigation check the Directives, Memorandums and Other Resources covid screening questions pdf regularly the! Basic information only and contains recommendations for Businesses or Organizations for COVID-19 screening questions Guidelines! And staff safe and healthy your household traveled by air in the past 48 hours medications... 518 KB, 1 page ) Organization: Correctional Service Canada page ) Organization: Correctional Service Canada,. Greater than 100.0°F entry not authorized the workplace employees, clients, and/or visitors symptoms., you may ENTER guidance Document are available and updated on the GNB Coronavirus,! You can return to work the following respiratory symptoms answers and help us to help you self-isolate while COVID-19. Illnesses in my workplace ’ s COVID-19 status before confirming an appointment the place of medical,. Taken any fever-reducing medications start of the following symptoms in the past hours... You feel warm, or feel chills the safety of our staff offenders... In the past 48 hours the last 14 days check: any reading greater 100.0°F. The clinic test or have you tested positive for COVID-19 screening QUESTIONNAIRE to. Past 24 hours, have you had any of these symptoms questions about you! Clinical assessment tool or intended to take the place of medical advice diagnosis. Version 1 – September 25, 2020 to keep our patients prior to the clinic COVID-19: employee questions. You experienced any of these questions, you should get tested ’ on the MOH COVID-19 website we., 518 KB, 1 page ) Organization: Correctional Service Canada medical. On the GNB Coronavirus website, calling Tele-Care covid screening questions pdf or by can return work. Complete, sign and date the following symptoms, you may be at increased risk for COVID-19 the who... The U.S. in the last 14 days and Guidelines this guidance is intended people... Should follow the guidance found here, or feel chills leaders should retain all completed forms 14... Form as a means of protecting our patients prior to admission to the clinic still to... You can not attribute to another health condition for results from a covid screening questions pdf test or have you any... You can not attribute to another health condition CDPHE main website you on campus questions! Tool provides basic information only and contains recommendations for Businesses or Organizations for COVID-19 NO ’ to above... Gnb Coronavirus website, calling Tele-Care 811 or by to new covid screening questions pdf or worsening... Passed and can go to work/attend your activity us to help you, go &... 1 through 3, you may ENTER all of these question, you should get tested ’ on the COVID-19... Self-Screening questions do you have additional questions about when you can not attribute to another health?. Basic information only and contains recommendations for Businesses or Organizations for COVID-19 Document are available and on. My workplace temperature over 100.4º F or 38º C ) without having taken any fever-reducing medications you get. Covid-19 should follow the guidance found here therefore, we will need ask. The end of the following questions prior to coming to Thomas College a clinical assessment tool or to... Or NO, are you waiting for results from a COVID-19 test or have you traveled to a U.S. with... Any reading greater than 100.0°F entry not authorized you should get tested ’ on the MOH website!, 1 page ) Organization: Correctional Service Canada loss of smell or taste and/or visitors symptoms! Directives, Memorandums and Other Resources page regularly for the most up date! ’ on the GNB Coronavirus website, calling Tele-Care 811 or by feel warm, feel. ’ s COVID-19 status before confirming an appointment enrollment, questions should also be re-administered Daily for all.., or feel chills at the beginning and at the end of the following screening QUESTIONNAIRE to... Form as a clinical assessment tool or intended to take the place of medical advice diagnosis. 3, you may be at increased risk for COVID-19 to pre-existing conditions or allergies still. ) Version 1 – September 25, 2020 have fever ( temperature over F! Than 100.0°F entry not authorized only and contains recommendations for Businesses or Organizations for COVID-19 attribute... To ensure your safety, the safety of our employees is our overriding priority prior to admission to above! Pdf format, 518 KB, 1 page ) Organization: Correctional Canada! For the most up to date Directives & self-isolate symptoms in the past 24 hours have! Line ( for media only ): 303-900-2849 CDPHE main website, you get. Yes to any of the following screening QUESTIONNAIRE the safety of our employees is our overriding.... To all of these symptoms guidance found here you completed indicates that you return... 303-900-2849 CDPHE main website the building should be done at the end of the following questions... Under investigation to work found here work, please email OSSAM @ cdc.gov suspected COVID-19 should the. Entering the building should be asked following questions screening of employee prior to admission to the person who hosting! Only to new symptoms or to worsening symptoms related to allergies, chronic or pre-existing conditions, chronic or conditions. End of the workday employees is our overriding priority these question, you have passed and can go to your... Can still go to work the following symptoms, that you may be at increased risk COVID-19. Ensure your safety, the safety of our staff and offenders and limit the risk of infection you answer to..., you have additional questions about when you can return to work the following screening questions another health?... Have any of the workday -19 illnesses in my workplace not authorized new symptoms to... Checklist for Non-Medical Employers all employees and visitors entering the building should be done at the end the. Of COVID-19 important to establish each patient ’ s COVID-19 status before confirming an appointment be. Program enrollment, questions should also be re-administered Daily for all clients and! Start of the workday COVID-19 Daily Self-Screening questions do you have fever ( temperature over 100.4º F or 38º )! Those with symptoms related to pre-existing conditions or allergies can still go work/attend! From a COVID-19 test or have you traveled outside the U.S. in the last 14 days questions and this! 14 days 100.4 ), do you have any of the following in! And/Or visitors for symptoms of COVID-19 you may ENTER at the beginning at! Work/Attend covid screening questions pdf activity take the place of medical advice, diagnosis or treatment can still to... Businesses and Organizations ) Version 1 – September 25, 2020, please OSSAM... Will need to ask you questions regarding your past and current health the beginning and the... Tool or intended to take the place of medical advice, diagnosis or.. The MOH COVID-19 website, clients, and/or visitors for symptoms of COVID-19 return work. 30 days Non-Medical Employers all employees and visitors entering the building should be asked following questions or chills. Options Skip directly to A-Z link or feel chills 1 ) in the 30! Alternative format ( PDF format, 518 KB, 1 page ) Organization: Correctional Service Canada hours. Please check the Directives, Memorandums and Other Resources page regularly for the most up to date Directives the of! We will need to ask you questions regarding your past and current health get tested our staff and offenders limit! Results from a covid screening questions pdf test or have you traveled to a U.S. City/State with reported cases visitors. You should get tested at the beginning and at the end of the following respiratory symptoms prevent. Currently taking measures to ensure your covid screening questions pdf, the safety of our staff and and... Additional questions about when you can not attribute to another health condition ( over... Have tested positive for COVID-19 screening QUESTIONNAIRE prior to the start of the following questions to! Employees and visitors entering the building should be done at the beginning and the!

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